At the state government level
The already established provisions:
1. Each state was required to create the directorate of PHC since the 1980s to facilitate the practice of PHC in the states’ LGAs. Lately ONLY, these states are now being encouraged or required to develop state PHC (development) agencies, with the possibility of some direct funding from federal allocation (from the Health Act) to do so.
2. All medical and nursing schools were mandated to include PHC in their curricula; and some leadership posts in nursing in the state ministries of health will be unattainable by any nurse except she had obtained the community/PHC training certificate.
3. At least one school of health technology is required to be owned by each state and to train the community health extension workers there.
The problems:
1. The provision of a fully functional general hospital by the state government for each LGA (or even a comprehensive health centre whose general hospital component will be looked after by a specialist, or otherwise at least very experienced, general medical practitioner) is not specified anywhere in our health system; and so, left to the caprices of the state governments. In some places or for some times, there may even be general hospitals run by nurses only.
2. Without properly organised and effective general medical practice (i.e., primary medical care coverage or secondary health care) to take off the weight of any fallouts from the PHC system, and close to the people within their LGAs, many state governments are busy competing with the federal government to provide all sorts of dysfunctional tertiary health care services. They do this for the very reasons of meeting the obvious need from the combined failures of the primary and secondary health services. Ironically, had these effective PHC and SHC services been established and working well, there would have been no enormous need for these state tertiary hospitals in the first place; nor the need to compete with the federal government for their provision.
3. The two-way (and mutually check-mating) referral system between the PHC and SHC on the one hand and the SHC and THC on the other, possible because they are each superintended by their relevant specialist physicians, does not exist in the country. As the Riga Conference on PHC22, midway to the year 2000 from Alma-Ata, had observed, without this two-way referral system providing the PHC primary support system, it will be impossible for it to work as due!
At the federal level
The existing provisions:
1. The development for the first time in Nigeria of a national health policy based on PHC in 1988, at least in theory; with the aim of doing this properly in the country.
2. The creation of the National Primary Health Care Development Agency (NPHCDA) as a vital tool for the promotion of PHC in the country.
3. The recent signing of the National Health Act in 201423; with provision for funds for implementing PHC in the country; but which is taking so very long to get it to any functionality at all.
4. The numerous (though externally expertly influenced and funded; and therefore invariably vertical) programmes aimed at PHC implemented from the NPHCDA at Abuja; with a lot of statistics of numbers of staff and equipment and money expended, but with little or no measurable (or especially commensurate) health service functionality, sustainability or reasonable health index improvement outcomes. These have no basis of any sustainability without developing the states and LGA capacities for these programmes and services as due.
5. The continuous training of CHOs at the various federal training institutions, independent and with no reasonable links with the overall health professionals and systems, nor any communities of their envisaged specific practices, as surely the Nigerian-factor alternative PHC system; compared with the world’s best practices in these regards.
The problems:
1. The efforts that resulted in the very famous production of the Nigerian national health policy, as a first of its kind in the history of the country as a nation and based on PHC, failed to reproduce, if not advance, the minimal public health acts of the country, even if only at the level of the colonial era, for the health services of the LGAs. The efforts to produce one by a draft approved at a National Council on Health in 199924, failed to be effected for reasons yet to be known. However, this is most likely because while the overall national health acts and policies may be made at the national level, the public health acts in the country were made by the regional governments of the properly federating units then; unlike the present Nigerian state governments, that do not quite operate as such competent federating units. Largely as a matter of these non-federating unit capabilities by the states, they themselves have by and large failed to re-enact or upgrade and implement these old regional public health acts as due.
2. The NPHCDA has continued to function as a PHC IMPLEMENTATION agency, instead of a DEVELOPMENT one. The agency has kept creating or receiving programmes and finances from international development partners (or some national ones) and going directly to implement those in their sponsors’ self-chosen places or communities. In virtually all the cases, the NPHCDA has been bypassing the state governments as well as many times, the LGAs and communities themselves. As I am reliably informed at a recent job assistance at the Federal Ministry of Health, besides the fact that everybody can see these naturally in the country, less that 20% of the “PHC” facilities built in these ways are functioning in ANY ways. Even in those “functioning 20%”, none of these has functioned at their intended full capacity. Only partial efforts to develop the state PHCDAs have started with the enactment of the National Health Act; an activity that should have been the priority of the NPHCDA from its very creation! Meanwhile, nothing in any of these recent actions has discussed the functionality and sustainability of the PHC itself at the LGA level, as in the best world best practices. Only individual states can make these decisions and implement them properly.
3. One of the funniest implementation of PHC from the federal government level through the NPHCDA that has happened, was the so-called community midwifery service scheme25. In this programme, the NPHCDA was largely to get a National Youth Service Corp type, but rapidly trained young girls as midwives but with no nursing training as yet. Without any requisite field experience, these young and unmarried, singly midwifery-only but not nursing qualified girls, were to be posted to various very remote places where they will be functioning as the sole midwives there; with counterpart salary payments required by the programme from the state or local governments. After some years of such services, the state or LGA was to take over the payment of the salaries and other conditions of service of those young girls. Anybody who had properly trained in, understands community health, or worked where these have been properly practiced, would easily tell that such a plan was a disaster – both for those girls as well as to any African nation that tries to do so. This is so because the years of marriageability of these young ladies, where the fairly early marriage of such young girls in whom much has been invested is of such great importance, is being wasted where these cannot take place in any meaningful ways! Moreover, community nurse-midwives are usually very experienced nurse-midwives who eventually act as health matriarchs(the communities’ mothers in relation with their health and welfare, as William Rathbone described them as long ago as 1859!)10. Moreover, no local government as currently being run in Nigeria can take over and sustain the funding and services of such health workers. Many of the state governments are also not likely to absorb such staff, with the indigene/non-indigene discrimination in the state government employments in this country, even in the most desperately under-served states in the country!
4. Both the Federal Government and especially the NPHCDA keep insisting that the PHC and the health services as provided from the states in the country should be the same in all the states. Anybody who has lived in such big and variegated countries (as Nigeria surely is) would know that this is never ever going to happen; and to insist that this must be the case, is EXACTLY how to ensure that the health services in such possibly frontline states for this progression, and country as a whole, will never improve as they ought.
5. Failure to repair the creation of a so-called PHC work force, unlike and parallel with the internationally accepted best world model of creating these auxiliary work force, is such a sore issue in the Nigerian health services.This was created from the federal level, and is surely a continuing problem in these regards. Even the Nigerian history teaches us enough of these things. The assistant medical officers produced at the Yaba Medical School, eventually all got their advancements to full-fledged medical doctors through the British conjoint further training programmes organised for them in the UK; and most of those doctors have proven to be some of the best full-fledged doctors that this country has ever produced – the likes of Profs. TO Ogunlesi, JO Mabayoje, Drs. Michael Okpara, Christopher Okojie, to name just a few! The other such trainings (like the Kano Medical School one) trained such staff for only the time that they were needed; and they practiced only in that region as was fashioned and licensed for; etc. The application of a similar principle and phasing out of the programmes or retaining them only for carefully community selected fellows, where they still need them, is an urgent necessity in the country.
